Traumatic Brain Injury 101 Causes, Consequences Coping Strategies

Traumatic Brain Injury 101: Causes, Consequences & Coping Strategies Brain Injury Association of Ohio Staff Members: Suzanne Minnich, Ex. Director Rich Haddix, CSN Coordinator Area 11 Jennie Horner, CSN Coordinator Area 5 Special thanks to our panelists 1 March 20, 2008 Objectives      Increase knowledge of demographics & scope of brain injury Gain understanding of common consequences and challenges following brain injury Better understand the impact on the individual and his or her family Learn about BIAOH & other sources of information & assistance in a state where TBI lacks a “home” agency within government. Identify skills and strategies to assist individuals with brain injury 2 Brain Injury Association of Ohio: Key Program Staff      State Office-Columbus + CSN 1, Toledo: Christine Veronie CSN 3, Cleveland: Lori Surtman CSN 5, Lima: Jennie Horner CSN 8, New Philadelphia: Chris Curtiss CSN 11, Columbus: Rich Haddix CSN 12, Caldwell: Jenny Rucker CSN 13, Cincinnati: Peggy O’Neill CSN 15, Marietta: Cindy Auker     BIAOH‟s goal is to create a comprehensive, statewide, resource facilitation system providing information, service linkage, education, and advocacy benefiting children & adults with brain injury and their families; the system‟s blueprint is known as “The Ohio Plan”. 3 What is the Brain Injury Association of Ohio? • Statewide education & advocacy organization for people with brain injury & their families • Affiliated with BIAA (Brain Injury Association) - 1 of 44 State Affiliates • Grassroots/Consumer Directed Organization, started by families, medical & rehabilitation professionals • Non-Profit, Tax Exempt Organization incorporated in 1983 4 Who Are the People Behind BIAOH • Board of Trustees - Who govern the organization, setting direction and providing oversight • Staff - Who implement its programs (13 or 10 FTEs) • Volunteers (in addition to Board Members) serving in many capacities, including as support group leaders • Members & Constituents • Collaborating Organizations & Partners • Funders & Supporters 5 What is BIAOH‟s Purpose?  Vision: A world where all preventable brain injuries are prevented, all unpreventable brain injuries are minimized and all individuals who have experienced brain injury maximize their quality of life Mission: To create a better future through brain injury prevention, research, education and advocacy 6  What Are BIAOH‟s Services & Supports      Information & Resource Coordination:  Helpline  Community Support Network (CSN) field offices located throughout the state Education & Training Peer Support Outreach & Prevention Advocacy 7 What is BIAOH‟s Central goal & why is it so important? Unlike disability populations of comparable size, there is no state agency responsible for addressing the needs of those with BI. 8 Contacting BIAOH is easy . . .  1-866-644-6242 (1-866-OHIO-BIA) Toll-free Helpline within Ohio help@biaoh.org www.biaoh.org   9 What is a Brain Injury? Acquired Brain Injury (ABI)  Traumatic Brain Injury (TBI)  10 Acquired Brain Injury  Any injury to the brain that occurs after birth as a result of: • Physical force (due to an accident)  Tumors • Strokes • Violent Acts (e.g., gun shot wound) • Infectious Diseases (e.g., encephalitis) ABI is the broadest category and includes all brain injuries that occur after birth. • 11 Traumatic Brain Injury  A brain injury from an external force • • • • • Vehicle accidents Violent Acts (e.g., gun shot wound) Falls Physical Abuse Sports Injuries 12 Severity Continuum Things to Consider  Symptomology  Pre-injury functioning  Symptoms vary Mild Moderate Severe 13  15% of all TBIs are considered moderate to severe  85% of all TBIs are considered mild 14 Severe Brain Injury  Severe Brain Injury Almost always results in prolonged unconsciousness or coma, brain contusions, hematomas, damage to nerve fibers and axons, and/or anoxia • Often results in permanent physical, behavioral, and/or cognitive impairments • Significant improvements are generally made during the first 1-2 years and continue thereafter at a slower rate • (Glascow Coma Scale score 3-8) 15 Epidemiology  An estimated 5.3 million Americans have a long-term or life long need for help with activities of daily living as a result of TBI (est. 227,000 Ohioans) An estimated 1.4 million people will sustain a TBI each year in the United States.  Of these:  50,000 die;  235,000 are hospitalized  1.1 million are treated and released from an ER  *The number of people with TBI who are not seen in an ER or who receive no treatment is unknown. 16 Disability Prevalence Rates 400,000 with Spinal Cord Injuries 500,000 with Cerebral Palsy 2 million Americans with Epilepsy 3 million with Stroke disabilities 4 million with Alzheimer’s Disease 5 million with persistent mental illness 5.3 MILLION WITH TBI DISABILITY 7.3 million Americans with mental retardation National organizations’ web sites, 4/00; Slide source: Brain Injury Association of America 227,000 Ohioans - Estimate of adults living w/disability due to TBI - source 17 Leading Causes of TBI 1st Falls (among elderly and very young) 2nd Vehicle accidents, bicycle, or pedestrian-vehicle incidents (account for most hospitalizations) 3rd Violent acts 4th Sports accidents – An estimated 90% are mild and go unreported (Source: BIA of America Fact Sheet) 18 If you have a brain injury, you are 3 times more likely to get another. After the second injury, the risk for the third injury is 8 times greater. 19 Who experiences brain injuries?  Extremely Diverse  Highest risk     and older Males are 1.5 times more likely than females to experience TBI 70% of people who incur TBI recover “completely” 15% remain symptomatic for the remainder of their lives Alcohol is reported to be associated with 50% of all TBI 20 0-4 years, 15-24, and 75 years TBI is the leading cause of death and disability for children, adolescents, and young adults in the United States. 90,000 of those injured will sustain permanent injuries. (www.biausa.org) 21 Neuroanatomy and Physiology of the Brain Deficits vary depending upon location and severity of brain injury  Major Brain Areas • Frontal Lobe • Parietal Lobe • Temporal Lobes • Occipital Lobe • Cerebellum • Brain Stem 22 Simplified Brain Behavior Relationships Frontal Lobe • Initiation • Problem solving • Judgment • Inhibition of behavior • Planning/anticipation • Self-monitoring • Motor planning • Personality/emotions • Awareness of abilities/limitations • Organization • Attention/concentration • Mental flexibility • Speaking (expressive language) Parietal Lobe Parietal Lobe Frontal Lobe Temporal Lobe Cerebellum Brain Stem • Sense of touch • Differentiation: size, shape, color • Spatial perception • Visual perception Occipital Lobe Occipital Lobe • Vision Cerebellum • Balance • Coordination • Skilled motor activity Temporal Lobe • Memory • Hearing • Understanding language (receptive language) • Organization and sequencing Brain Stem • Breathing • Heart rate • Arousal/consciousness • Sleep/wake functions • Attention/concentration 23 (Almost always sustains injury due to coup-contra-coup & boney undersurface of skull; domaine of “executive functions”; damage to this portion of the brain – and resulting deficits – considered to be the “thumbprint of brain injury”) Frontal Lobe           Problem Solving Planning Judgment Abstract thought Memory Self-monitoring Attention/Concentration Organization Inhibition of Behavior Initiation 24 25 Parietal Lobe       Sense of touch Sensory integration Spatial perception Visual perception Identification of size, shape, color Language comprehension 26 Temporal Lobe  Interpretation of speech/Receptive language Memory of new information Organization & Sequencing Hearing Ability to identify smells and sounds     27 Occipital Lobe  Vision Ability to process visual info. Ability recognize shapes, colors, letters and words 28   Cerebellum     Balance Coordination Skilled motor activity Posture 29 Brain Stem       Breathing Arousal and consciousness Sleep/wake cycles Attention and concentration Heart rate Basic life functions 30 TRAUMATIC BRAIN INJURY 31 Living with a Brain Injury: The Impact on the Individual • Physical • Cognitive • Social • Behavioral & Emotional 32 Physical Disabilities         Headaches Dizziness Chronic pain Seizures Decreased coordination, balance problems Loss of limbs or use of limbs Nerve Damage (i.e., optic nerve, facial palsy) Sensory limitations (visual disturbances, hearing loss, decreased taste and smell, increased sensitivity to noise and light) 33 Cognition  Broad range of symptoms that occur independently or in combination • • • • • • Memory impairment Impaired attention Inability to remain on task Difficulty focusing on thoughts, words, events Deficits in language use Deficits in visual perception 34 Executive Skills – the “thumbprint” of brain injury  Cognition-Deficits in    Inability to self-monitor and inhibit responses Poor initiation Difficulty sequencing steps and completing activities Poor judgment 35 Social           Difficulty attending to social cues Relearning appropriate social skills Loss of friends Loss of familiar activities Loss of self Personality changes Problems with emotional control Susceptible to mood and anxiety disorders Increased risk of suicide Egocentric 36 Behavioral and Emotional          Frustration Irritability Restlessness Anxiety Low self esteem Depression Emotional Lability (Mood Swings) Behavioral Outbursts Disinhibition 37 Medications Properly prescribed & closely monitored medications can help individuals w/BI deal with physical, emotional, and/or behavioral impairments due to TBI. 38 Medications  Often on multiple medications   Need for continued re-assessment Physical Medicine & Rehabilitation (PMR) doctors, experienced in working with those with BI, are especially helpful. (AKA – physiatrists) 39 • SSRIs (e.g., Prozac) often prescribed for anxiety and depression • Anticonvulsants (e.g., Tegretol) often prescribed to prevent seizure activity or to treat behavioral problems • Sleep medications (e.g., Melatonin) often prescribed for sleep disturbances • Neuroleptics (e.g., Risperdal) prescribed for psychosis and/or aggression Substance Abuse  Higher rates of substance abuse • Effects 28%-32% of individuals with TBI 40 Practical Adaptations/Accommodations 41 Reasoning/Problem Solving Signs . . .  Accommodations . . . Instruct and post note for “Stop and Think” Help identify the problem and possible solutions Help predict consequences Break the task down into several easier steps Write steps in notebook/planner 42 Inappropriate and potentially harmful decisions Unable to make inferences     Disorganized thinking Difficulty drawing conclusions Rigidity in changing plans      Attention/Concentration Signs . . .    Accommodations . . .    Confusion Rambling Conversations Staring Unable to finish a task Difficulty attending to more than one thing at a time    Get individual‟s attention before beginning a discussion Reduce unnecessary noise or unneeded materials on desk Limit the amount of information presented Pace the work with short work periods followed by brief breaks 43 Memory Loss Signs . . .     Accommodations . . .       Confusion regarding appointments or daily schedule Unable to remember tasks from day to day Unable to remember new information Confabulates (makes up stories to fill memory gaps; this is not lying) Establish consistent schedule Structure tasks Provide written cues (memory book, chart, etc.) Provide verbal cues (initial sounds, choices) Use compensatory tools (alarm, watches, calculators) Link new information with old information 44 Loss of Impulsivity/Poor Self Control Signs . . .   Accommodations . . .      Acts or speaks without considering the consequences Inappropriate comments to or about others Lower tolerance for frustrating situations Inappropriate laughing or crying Gets stuck on one idea or thought      Encourage the person to slow down and work through task Provide verbal and/or nonverbal feedback in a supportive way Respond to inappropriate ideas, but maintain focus on original discussion Expect the unexpected Provide alternatives for inappropriate or perseverative behavior Give frequent and consistent positive reinforcement Remove the individual from a frustrating task or environment 45 Impaired Self-awareness, Difficulty with Social Situations Signs . . .  Accommodations . . .    Lack of awareness of deficits and limitations Inaccurate self-image/self perception   Anticipate lack of insight Prompt accurate selfstatements Use feedback generously in a positive way Give realistic feedback as you observe behavior 46 Problems with Conversations Signs . . .  Accommodations . . .     Does not respond to another person‟s conversation, questions or comments Does not start, or is slow to start conversations, ask questions, or make comments Leaves long pauses Has difficulty explaining what he or she means     Encourage the individual to participate, e.g., ask “What do you think about that?” Ask open-ended questions; “Tell me about…” Give time to organize thoughts Give the individual your full attention and allow them to complete the thought Re-phrase what the person has said, “Do you mean…” 47 Problems w/Non-verbal Communication Signs . . .     Accommodations . . . Ask the person to maintain a comfortable distance Politely ask the individual to modify their physical contacts; explain that you are uncomfortable with such contact Tell the person you are confused by the difference in body language and spoken message Ask the person what he or she is feeling Politely ask the individual to stop distracting movements   Poor eye contact Does not understand non-verbal cues Stands too close Uncomfortable number/type of physical contacts Body language/facial expressions don‟t seem to “match” what is said (flat affect)     48 General Suggestions      Structure the environment Break tasks into component parts Pace the work (consider headaches, fatigue, etc.) Help develop organizational systems BE CONSISTENT 49 Other considerations . . .  Accommodate for both cognitive and physical fatigue – they often impact multiple areas of functioning When thinking through a person‟s A-B-C patterns (antecedents, behavior, consequences), recognizing & addressing antecedents to undesirable behavior often is more effective than an emphasis on consequences. Ditto to increase positive behaviors.   A person-centered, individualized approach is paramount 50 Resources to Remember  TBI Technical Assistance Center at NASHIA (National Association of State Head Injury Administrators)„ http://www.tbitac.nashia.org/tbics/ Brain Injury Association of America (Their mission is to create a better future through brain injury prevention, research, education and advocacy): www.biausa.org Brain Injury Association of Ohio (BIAOH) 1-866-644-6242 www.biaoh.org 51 March is Brain Injury Awareness Month  Pick up a green “mind matters” wrist band Consider wearing it through the end of the month & share with others information you‟ve learned about BI  Thank you & safe travels! 52